NURS 432 psych lec- unit 2

Ben Martin

schizophrenia

📌 Core Concept

• Syndrome (NOT one disease) → wide range of distorted thoughts, perceptions, emotions, and behaviors

• Chronic, severe mental illness but manageable with treatment

• ⚠ Old myth: violent/uncontrollable → ❌ Incorrect
  → Most clients live in community with meds + support

📊 Onset:

• 👨 Men: 15–25 yrs

• 👩 Women: 25–35 yrs

• Rare in childhood

👉 young adult with new psychosis = think schizophrenia

🔑 Symptom Categories:

➤ Positive Symptoms (ADDED behaviors) = “Hard”

👉 Respond BEST to meds

• Delusions

• Hallucinations (often auditory)

• Disorganized thinking / speech

• Bizarre behavior

➤ Negative Symptoms (LOSS of function) = “Soft”

👉 Persist + harder to treat!

• Flat affect (no emotion)

• Avolition (lack of motivation)

• Anhedonia (no pleasure in activities)

• Social withdrawal

• Inattention

💊 Treatment Concepts

• Atypical (2nd-gen) antipsychotics = first-line

• Abilify (aripiprazole), Risperdal (risperidone), Zyprexa (olanzapine), Seroquel (quetiapine)

• Most effective for:

  • ✅ Positive symptoms

  • ❌ Less effective for negative symptoms

🔀 Schizoaffective Disorder (Know the Difference!) 📌

• Combination of:

  • Psychotic symptoms (like schizophrenia)

  • Mood disorder symptoms (depression or bipolar)

🧠 Subtypes & Outcomes

• Bipolar type → outcomes similar to bipolar disorder

• Depressive type → outcomes similar to schizophrenia

💊 Treatment

• Second-generation antipsychotics (FIRST)

• Mood stabilizers (if bipolar)

• Antidepressants (if depressive)

2. Communication

• Do NOT reinforce delusions

• “I understand that feels real to you” - Present reality briefly

🧩 “Think Like a Nurse” (Clinical Judgment)

• New psychosis in young adult → suspect schizophrenia

• Hallucinations improving but client still withdrawn → negative symptoms

• Client stops meds → HIGH relapse risk

• Mood + psychosis → think schizoaffective

bipolar disorder

📌 Info

• Cycles of mania + depression

• High disability + ↑ suicide risk (~15%)

• Equal in males/females

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💊 Pharm

• Lithium = first-line (NCLEX favorite)

• Anticonvulsants

• Avoid antidepressants alone (can trigger mania)

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🛠 Treatment

• Psychotherapy (maintenance phase)

• ❌ Not effective during acute mania

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🩺 Nursing Process Assessment (Mania)

• Euphoria, grandiosity

• ↓ need for sleep

• Rapid, tangential speech

• Poor judgment, impulsivity

• Hyperactivity

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Diagnoses

• 🚨 Risk for injury (PRIORITY)

• Sleep deprivation

• Impaired social interaction

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Outcomes

• No injury

• Adequate sleep/rest

• Appropriate behavior

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Interventions

• 🚨 Safety first

• Reduce stimuli

• Set firm limits

• Promote sleep/rest

• Meet nutrition/fluids

suicide

📌 Key Points

• Intentional self-harm → often linked to depression

• Men complete more suicides

• Suicide = ambivalence

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🚨 Assessment

• Previous attempts (highest risk: first 3 months)

• Plan, means, intent (lethality)

• Family history

• Warning signs (behavior changes)

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🎯 Outcomes

• Maintain safety

• Develop support system

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🛠 Interventions

• ⚠ Authoritative approach

• Directly ask about suicide

• Remove harmful objects

• Close monitoring

• Build support system

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👨‍👩‍👧 Family/Nurse Response

• Family: guilt, shame, anger

• Nurse: nonjudgmental, therapeutic presence

• Self-awareness essential

mood disorders

• Pervasive disturbances in emotion (depression, mania, or both)

• Cause functional impairment

• Historically untreated until antidepressants (1950s)

• Depression = most associated with suicide

categories

• Major Depressive Disorder (MDD) (≥2 weeks)

• Bipolar I & II

• Dysthymia (persistent depressive disorder)

• Cyclothymia (cycles of mania & depression, but less severe than bipolar)

• Substance-induced mood disorders

• Seasonal affective disorder

• Postpartum disorders (blues, depression, psychosis)

• Premenstrual dysphoric disorder

etiology

• Biologic:

  • Genetics (family history ↑ risk)

  • ↓ serotonin, norepinephrine, dopamine

  • Neuroendocrine (hormonal influences)

• Psychosocial:

  • Cognitive distortions (negative thinking)

  • Low self-esteem/self-deprecation

  • Loss, trauma, poor parenting

  • Mania = defense against depression

cultural considerations of mood disorders

some behaviors can mask sx of these disorders.

• Children → behavior issues (cranky, school problems, learning disorders, hyperactivity, antisocial)

• Adolescents → substance use, risk-taking, drop out

• Adults → substance abuse, compulsive behaviors, workaholism, gambling

• elderly → crankiness or argumentativeness may be depression

• Depression may present as somatic complaints, esp in nonverbal cultures. Some cultures avoid emotional expression

pharmacology for mood disorders

• Antidepressants:

  • SSRIs → first-line, safe for elderly, minimal s/e that decrease in days, but watch for serotonin syndrome

  • TCAs → take 6 weeks to feel effects, cannot be combined with MAOI, have anticholinergic s/e, contraindicated in liver/cardiac impairment

  • MAOIs → uncommon bc of risk for ⚠ hypertensive crisis- a life-threatening condition that can result when a client taking MAOIs ingests tyramine-containing foods (cheeses (cheddar, blue, Swiss), cured or processed meats (salami, pepperoni, bacon), fermented soy products (soy sauce, miso), sauerkraut, tap/craft beers, red wine)

  • Atypicals- Effexor, Cymbalta, Wellbutrin - given when others don’t work.

• Mood stabilizers:

  • Lithium (first-line for mania)

  • Anticonvulsants

• Meds treat symptoms → require adherence + monitoring

Major Depressive Disorder (MDD)

📌 Info

• Episode ≥ 2 weeks (can be years)

• anhedonia and changes in weight, sleep, energy, concentration, decision-making, self-esteem, and goals

• May include psychotic features

💊 Pharm

• SSRIs = first-line

• TCAs, MAOIs, atypicals

• Monitor for:

  • Serotonin syndrome

  • Suicide risk (early treatment)

🛠 Treatment

• ECT → severe, suicidal, or psychotic depression. safe for pregnancy. need 10-15 txs. placed on ECG to monitor seizure activity

• Psychotherapy:

  • CBT (cognitive distortions)

  • Interpersonal therapy

  • Behavioral therapy

🩺 Nursing Process Assessment

• Anhedonia (hallmark)

• Psychomotor retardation/agitation

• Suicidal ideation (PRIORITY)

• Worthlessness, hopelessness

• Impaired memory, judgment

Diagnoses

• 🚨 Risk for suicide (PRIORITY)

• Hopelessness

• Self-care deficit

• Social isolation

Outcomes

• Free from self-harm

• Perform ADLs

• Balanced sleep/activity

• Medication adherence

Interventions

• 🚨 Suicide precautions

• Therapeutic communication

• Promote ADLs

• Monitor meds

• Client/family teaching

Schizophreniform Disorder

• Same symptoms as schizophrenia

• ⏱ < 6 months

• May or may not impair functioning

If symptoms continue > 6 months → becomes schizophrenia

Brief Psychotic Disorder

• Sudden onset psychosis

• ⏱ 1 day to 1 month

• Often follows stress or postpartum

👉 Think: SHORT + sudden

Delusional Disorder

• Non-bizarre delusions only

  • (could actually happen in real life)

• Types:

  • Persecutory, grandiose, jealous, erotomanic, somatic

• ✅ Functioning mostly intact

Client appears “normal” except for fixed delusion

catatonia

Extreme psychomotor disturbance

Can be:

• 🧊 Immobility:

  • Stupor

  • Catalepsy (waxy flexibility)

• ⚡ Excess movement:

  • Purposeless, not stimulus-driven

Other signs:

• Mutism

• Negativism

• Echolalia (repeat words)

• Echopraxia (imitate movements)

👉 Occurs in: Schizophrenia & Mood disorders

Shared Psychotic Disorder (Folie à deux)

• Shared delusion between 2 people

• Usually:

  • Close relationship

  • One dominant, one submissive

• Separation → improvement

biologic theories of schizophrenia

1. 🧬 Genetic Factors

• Polygenic inheritance (multiple genes)

• increased risk with IDENTICAL TWINS, both parents, fraternal twins, one parent

2. 🧠 Neuroanatomic & Neurochemical Factors 🧩 Brain Structure Changes:

• ↓ Brain tissue, Enlarged ventricles, Cortical atrophy, ↓ frontal lobe activity (thinking, motivation), Temporal lobe involvement (psychosis)

👉 Correlation:

• Frontal lobe → negative symptoms

• Temporal lobe → positive symptoms

⚡ Neurotransmitters

• Excess dopamine → psychosis

• tx- dopamine blockers

• Serotonin modulates dopamine, may also contribute to symptoms

3. 🦠 Immunovirologic Factors

• Viral exposure, Immune response changes, Cytokine involvement

Risk Factors:

• Maternal infection (e.g., influenza), Prenatal stressors, Poor intrauterine environment

pharmacology for schizophrenia

🧠 Key Neurotransmitters

• Dopamine (primary target) → drives positive symptoms

• Serotonin (secondary target) → influences negative symptoms & mood

🧪 Antipsychotics (Neuroleptics)

• Main treatment (NOT a cure) → used for symptom control

• ↓ psychosis (hallucinations, delusions, disorganized thinking)

1⃣ First-Generation (Conventional) Antipsychotics

Mechanism: Dopamine antagonists

• ✅ ↓ Positive symptoms (hallucinations, delusions)

• ❌ No effect on negative symptoms

2⃣ Second-Generation (Atypical) Antipsychotics** first-line

Mechanism: Dopamine + serotonin antagonists

• ✅ ↓ Positive symptoms

• ✅ ↓ Negative symptoms (apathy, lack of motivation, social withdrawal, anhedonia)

🔄 Maintenance Therapy (Long-Acting Injections – LAIs)

• Purpose: Improve medication adherence

• Duration: ~2–4 weeks per injection

• Require oral trial first to reach stable dose

  • ❌ NOT for acute psychosis

• Best for: Nonadherence, Long-term management, Supervised treatment

• these 6 are: Zyprexa PRObably HAlD the ABILIty to RISkperdal $ INVEGAs

• •Fluphenazine (Prolixin)

  •Haloperidol (Haldol)

  •Risperidone (Risperdal)

  •Paliperidone (Invega Sustenna)

  •Olanzapine (Zyprexa)

  •Aripiprazole (Abilify)

elder considerations with schizophrenia

• uncommon over the age of 45

• can be r/t dementia or depression

• ppl with schizophrenia have increased risk for dementia

Assertive community treatment (ACT)

proven to be most effective in managing schizophrenia.

an intensive, team-based, outpatient mental health service for individuals with schizophrenia who often struggle with traditional office-based care. ACT teams provide medication management, therapy, and housing support, directly in the community to prevent hospitalizations and promote recovery

• reducing the rate of hospital admissions by managing symptoms and medications; assisting clients with social, recreational, and vocational needs; and providing support to clients and their families

prodromal signs

think PRE- schizophrenia signs.

• early warning signs that psychosis may develop

• sleep difficulties, change in appetite, loss of energy and interest, odd speech, hearing voices, peculiar behavior, inappropriate expression of feelings, paucity of speech, ideas of reference, and feelings of unreality

schizophrenia onset & course

🔍 Early (Prodromal) Signs (not full diagnosis yet)

• Social withdrawal

• Decline in school/work performance

• Poor hygiene

• Odd/unusual behavior

👉 Diagnosis typically occurs when POSITIVE symptoms appear:

• Delusions

• Hallucinations

• Disorganized thinking

⚠ Prognosis Factors→ ❌ Poor Outcomes Associated With:

• Early age of onset

• Gradual (insidious) onset

• Prominent negative symptoms

• Cognitive impairment

• Poor premorbid functioning

✅ Better Outcomes Associated With:

• Later onset

• Acute/sudden onset

• Good prior functioning

🚨 Major Relapse Triggers:

• Medication nonadherence

• Substance use

• Critical/hostile family environment

• Negative attitude toward treatment

📊 Immediate-Term Course (2 Patterns)

1. Chronic pattern

   • Ongoing psychosis

   • Never fully recovers

2. Episodic pattern

   • Psychotic episodes

   • Periods of near full recovery

👉 NCLEX Tip:
If question mentions “cycles” → think episodic course

📉 Long-Term Course

• Psychosis decreases with age

• Illness becomes less disruptive over time

⚠ BUT:

• Many have persistent impairment

• Few achieve full independence

Longer untreated psychosis → worse prognosis

Early identification + treatment = BEST long-term outcome

🧠 “Think Like a Nurse”

• Subtle withdrawal in teen → monitor for prodromal schizophrenia

• First psychotic episode → URGENT treatment needed

• Client stops meds → expect relapse

• Chronic negative symptoms → focus on function, not cure

🚨 NCLEX Quick Hits

• Gradual onset = worse prognosis

• Early onset = more severe disease

• Med nonadherence = top relapse cause

• Psychosis ↓ with age but function often remains impaired

• Early treatment = improves quality of life + reduces relapse

culture-bound syndromes

localized “folk” illnesses only occurring within one group

• susto- latino - A sudden, frightening event (e.g., accidents, deaths, trauma) is believed to cause the soul to leave the body, resulting in illness. sx- restlessness, listlessness, weakness, diarrhea, muscle pain, and depression.

• koro - Asia / Africa - acute, overwhelming anxiety that one’s genitals (or breasts) are shrinking, retracting into the body, or disappearing. Sufferers fear imminent death or sexual dysfunction, often stemming from cultural beliefs in magic, witchcraft, or masturbatory guilt

• Bouffée délirante - West Africa and Haiti, characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement.

• Ghost sickness - Native American tribes- preoccupation with death and the deceased. sx- bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation.

• Jikoshu-kyofu - Japan- a fear of offending others by emitting foul body odor

• Locura - latino- chronic psychosis. sx- incoherence, agitation, visual and auditory hallucinations, inability to follow social rules, unpredictability, and, possibly, violent behavior.

• Qi-gong psychotic reaction- China- acute, time-limited episode characterized by dissociative, paranoid, or other psychotic symptoms that occur after participating in the Chinese folk health-enhancing practice of qi-gong.

• Zar- Africa & Middle East- an experience of spirits possessing a person. The afflicted person may laugh, shout, wail, bang his or her head on a wall, or be apathetic and withdrawn, refusing to eat or carry out daily tasks.

side effects of antipsychotics (THEY’RE CRAZY)

🧠 1. Neurologic Side Effects

⚠ Extrapyramidal Symptoms (EPS) — EARLY, REVERSIBLE

🔹 Dystonia (Acute, emergency): Muscle spasms (neck = torticollis, eyes = oculogyric crisis). Airway risk ⚠ (laryngeal spasm)

• Treatment: diphenhydramine or benztropine

🔹 Akathisia - I can’t sit still - restlessness, pacing, anxiety

• Treatment: Beta-blockers (propranolol) = FIRST LINE, or Benzodiazepines

🔹 Parkinsonism- Shuffling gait, Mask-like face, Rigidity, drooling, slow movement

• Treatment: Anticholinergics (e.g., benztropine)

⚠ Tardive Dyskinesia (TD) — LATE, IRREVERSIBLE

• Lip smacking, tongue protrusion, grimacing, limb movements

• ↓ dose or stop drug → prevents worsening

• Treatment: Valbenazine, deutetrabenazine; Switch to clozapine (lower risk)

• Monitoring: Use AIMS scale every 3–6 months

⚠ Neuroleptic Malignant Syndrome (NMS) — LIFE-THREATENING

• High fever, Severe muscle rigidity, ↑ CPK, Leukocytosis

• 🚨 STOP antipsychotic immediately

• Emergency treatment

⚠ Clozapine (Clozaril)

• Risk for seizures

• Risk for agranulocytosis (↓ WBC → infection risk)

  • routine WBC monitoring

  • sx- fever, sore throat, malaise

🧾 2. Non-Neurologic Side Effects Common:

• Weight gain, Sedation, Photosensitivity

• Anticholinergic Effects: Dry mouth, Blurred vision, Constipation, Urinary retention

• Cardiovascular: Orthostatic hypotension

cognitive enhancement therapy (CET)

combines computer-based cognitive training with group sessions that allow clients to practice and develop social skills.

• designed to remediate or improve the clients’ social and neurocognitive deficits, such as attention, memory, and information processing.

• The experiential exercises help the client take the perspective of another person, rather than focus entirely on him or herself.

• results- increased mental stamina, active rather than passive information processing, and spontaneous and appropriate negotiation of unrehearsed social challenges

used with other behavioral / social therapies like group

schizophrenia & nursing process

🩺 1. ASSESSMENT (PRIORITY = SAFETY + PSYCHOSIS)

🔑 Key History

• Age of onset (earlier = worse prognosis)

• Prior suicide attempts (↑ risk)

• History of violence/aggression

• Medication adherence + hospitalizations

• Support systems

• Client’s perception of problem

👀 Appearance / Behavior / Speech

• Disheveled, bizarre dress

• Agitation OR catatonia (waxy flexibility)

• Speech: Word salad, Echolalia (involuntary repetition of words), Latency of response

😊 Mood & Affect

• Flat / blunted affect

• Inappropriate emotions (laughing at sad events)

• Anhedonia (negative symptom)

🧠 Thought Process & Content

• Thought disorders: blocking, insertion, withdrawal, broadcasting

• Delusions = fixed false beliefs (NOT reality-based)

👂 Perception

• Hallucinations (auditory most common)

• ⚠ Command hallucinations = DANGER

⚖ Insight & Judgment

• Poor insight → doesn’t recognize illness

• Poor judgment → unsafe behaviors

🧍 Functioning

• Self-care deficits (hygiene), Social isolation, Loss of ego boundaries

🧾 2. NURSING DIAGNOSES

🔴 Positive Symptoms

• Risk for violence (self/others)

• Disturbed thought processes

• Disturbed sensory perception

• Impaired verbal communication

🔵 Negative Symptoms

• Self-care deficit

• Social isolation

• Ineffective health management

🎯 3. PLANNING

🚨 Acute Psychosis (PRIORITY)

• Maintain safety

• Improve reality orientation

• Encourage interaction

• Express thoughts safely

• Adhere to treatment

🏠 Long-Term / Maintenance

• Medication adherence

• Independent self-care

• Adequate sleep/nutrition

• Social functioning

• Recognize relapse & seek help

🛠 4. IMPLEMENTATION

🚨 SAFETY FIRST

• Assess for: Suicide, Command hallucinations, Aggression

🧠 COMMUNICATION

• Use simple, clear, concrete language

• Do NOT argue with delusions
  → Say: “I don’t see that, but I understand it feels real to you”

👂 HALLUCINATIONS

• Present reality

• Assess content (esp. commands)

• Reduce stimuli

* Safety > reality orientation > socialization

trauma and stressor-related disorders

Traumatic events are extraordinary, severe stressors that would disrupt any person’s life, not just those with prior mental health risk.

• Trauma may affect:

  • Individuals (childhood abuse survivor, new diagnosis)

  • Large groups (war, terrorism, natural disasters)

Expected vs. Concerning Responses

Normal Response:

• Anxiety, Insomnia, Grief, Difficulty coping

• Temporary emotional distress → Most individuals gradually return to baseline functioning (sometimes with improved resilience).

When to Be Concerned (Persistent Impairment):

• Ongoing difficulty coping, Inability to manage stress/emotions, Trouble resuming daily activities

Possible Diagnoses if Symptoms Persist

• Adjustment disorder

• Acute stress disorder

• Posttraumatic stress disorder (PTSD)

• Dissociative disorders

anxiety

Vague feeling of dread or apprehension

• is unavoidable in life - can be helpful- motivating the person to take action to solve a problem or to resolve a crisis.

• It is considered normal when it is appropriate to the situation and dissipates when the situation has been resolved.

• can exhibit unusual behaviors such as panic without reason, unwarranted fear of objects or life conditions, or unexplainable or overwhelming worry. They experience significant distress over time, and the disorder significantly impairs their daily routines, social lives, and occupational functioning.

Different from fear (feeling afraid or threatened by identifiable stimulus representing danger)

anxiety can be stress-induced

• Stress: wear and tear that life causes on the body

• Marriage, children, airplanes, snakes, a new job, a new school, and leaving home are examples of stress-causing stimuli.

anxiety as a response to stress

General adaptation syndrome (physiological aspects of stress)

• Alarm reaction stage (preparation for defense)

  • stress stimulates the body to send messages from the hypothalamus to the glands (such as the adrenal gland, to send out adrenaline and norepinephrine for fuel) and organs (such as the liver, to reconvert glycogen stores to glucose for food) to prepare for potential defense needs.

• Resistance stage (blood shunted to areas needed for defense)

  • the digestive system reduces function to shunt blood to areas needed for defense. The lungs take in more air, and the heart beats faster and harder so that it can circulate this highly oxygenated and highly nourished blood to the muscles to defend the body by fight, flight, or freeze behaviors. If the person adapts to the stress, the body responses relax, and the gland, organ, and systemic responses abate.

• Exhaustion stage (stores depleted; emotional components unresolved)

  • the person has responded negatively to anxiety and stress; body stores are depleted or the emotional components are not resolved, resulting in continual arousal of the physiological responses and little reserve capacity

levels of anxiety

Mild anxiety- a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him or herself. It often motivates people to make changes or engage in goal-directed activity. For example, it helps students focus on studying for an examination.

Moderate anxiety- the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. The person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic. For example, the nurse might be giving preoperative instructions to a client who is anxious about the upcoming surgical procedure. As the nurse is teaching, the client’s attention wanders, but the nurse can regain the client’s attention and direct him or her back to the task at hand.

Severe anxiety and panic- more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten, and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional–psychomotor means to release tension.

• In panic, the emotional–psychomotor realm predominates with accompanying fight, flight, or freeze responses. Adrenaline surge greatly increases vital signs. Pupils enlarge to let in more light, and the only cognitive process focuses on the person’s defense.

working with anxious clients

• Self-awareness of anxiety level

• Assessment of person’s anxiety level

• Use of short, simple, easy-to-understand sentences

• Lower person’s anxiety level to moderate or mild before proceeding

• Low, calm, soothing voice even if the person isn’t comprehending it

• In panic, safety is primary concern. Panic-level anxiety can last from 5 to 30 minutes.

• Short-term use of anxiolytics- BENZOs (lams & pams) should be used for 4-6 weeks ONLY bc they have a high likelihood of abuse & dependence.

anxiety disorder info

most common mental health issue in the US

• More prevalent in: women; people under 45 years; people who are divorced or separated; people of lower socioeconomic status

• Related disorders-

• Selective mutism- diagnosed in children when they fail to speak in social situations even though they are able to speak. They may speak freely at home with parents but fail to interact at school or with extended family. Lack of speech interferes with social communication and school performance. There is a high level of social anxiety in these situations.

• Anxiety disorder due to another mental condition- diagnosed when the prominent symptoms of anxiety are judged to result directly from a physiological condition. The person may have panic attacks, generalized anxiety, or obsessions or compulsions.

• Substance/medication-induced anxiety disorder- directly caused by drug abuse, a medication, or exposure to a toxin. Symptoms include prominent anxiety, panic attacks, phobias, obsessions, or compulsions.

• Separation anxiety disorder- excessive anxiety concerning separation from home or from persons, parents, or caregivers to whom the client is attached. It occurs when it is no longer developmentally appropriate and before 18 years of age.

etiological theories of anxiety

🧠 Biologic Theories

Genetic-

• Anxiety disorders show genetic susceptibility (not direct inheritance)

Heritability levels:

• 0.6 = strong genetic influence

• 0.3–0.5 = moderate (most anxiety disorders- panic disorder, social anxiety, phobias)

• <0.3 = minimal genetic role

• Family patterns: GAD & OCD → suggest genetic link

Neurochemical-

• GABA (high GABA levels decrease anxiety): inhibitory → ↓ neuronal firing → calming effect. AKA decreased GABA can cause anxiety

• Norepinephrine (increases anxiety): excitatory → ↑ arousal. AKA increased norepinephrine can cause anxiety

• Serotonin: affects mood, aggression, anxiety (esp. OCD, panic, GAD)

🧠 Psychologic Theories

Psychodynamic (Freud)-

• Anxiety = internal conflict

• Defense mechanisms (unconscious) reduce anxiety

• Overuse → poor coping, impaired relationships, ↓ emotional growth

Interpersonal (Sullivan & Peplau)

• Anxiety = learned through relationships

• Originates from:

  • Poor caregiver interactions

  • Cultural/social pressures

• High anxiety → ↓ communication & problem-solving

Behavioral

• Anxiety = learned response

• Can be unlearned through new experiences (therapy)

• Focus = changing behaviors, not insight

cultural considerations of anxiety

• Asian cultures often express anxiety through somatic symptoms such as headaches, backaches, fatigue, dizziness, and stomach problems.

• Koro= a man’s profound fear that his penis will retract into the abdomen and he will then die. In women, koro is the fear that the vulva and nipples will disappear Tx- having the man firmly hold his penis until the fear passes, often with assistance, and clamping the penis to a wooden box.

• Susto= diagnosed in some Hispanic clients during cases of high anxiety, sadness, agitation, weight loss, weakness, and heart rate changes. The symptoms are believed to occur because supernatural spirits or bad air from dangerous places and cemeteries invades the body.

anxiety in the elderly

• frequently seen along with depression, dementia, physical illness, or medication toxicity/ withdrawal

• Phobias (agoraphobia, GAD) most common

• Panic attacks less common, often related to other illness

• Ruminative thoughts- obsessions, such as contamination fears, pathologic doubt, or fear of harming others.

tx-

• SSRI antidepressants are BEST, but given in lower initial doses than usual to ensure the client can tolerate it. If started on too high a dose, SSRIs can exacerbate anxiety symptoms in elderly clients.

• Benzo use in elderly is risky, but still done :(

tx for anxiety

best to use multifaceted approaches

• Cognitive–behavioral therapy (CBT):

  • Positive reframing- turning negative messages into positive messages

  • Decatastrophizing (making more realistic appraisal of situation)

  • Assertiveness training (learn to negotiate interpersonal situations)

• Antidepressants

• BENZOs (lams & pams) should be used for 4-6 weeks ONLY bc they have a high likelihood of abuse & dependence.

stress & anxiety management

Core Principles

• Promote positive coping mindset: self-confidence, realistic thinking, acceptance of uncontrollable events

• Goal is management (not elimination) of anxiety to improve functioning and quality of life

Effective Stress-Management Strategies

1. Cognitive & Emotional Coping

• Maintain a positive attitude and belief in self

• Accept lack of control over certain situations

• Use assertive communication to express needs and feelings

• Encourage emotional expression (talking, laughing, crying)

2. Lifestyle Modifications

• Regular exercise

• Balanced nutrition

• Adequate sleep/rest

• Limit stimulants (caffeine) and depressants (alcohol)

3. Behavioral & Relaxation Techniques

• Practice relaxation strategies (deep breathing, meditation, guided imagery)

• Engage in personally meaningful activities

• Set realistic goals and expectations

Clinical Nursing Insight

• Medications may reduce symptoms, but do not address underlying stressors

• Long-term improvement requires coping skills + behavioral strategies

• Teaching stress management is a key nursing intervention

panic disorder

Characterized by recurrent, unexpected panic attacks (no identifiable trigger)

• common in late adolescence - 30s

• Diagnosis requires:

  • ≥1 month of persistent worry about future attacks OR

  • Behavioral changes (e.g., avoidance)

Panic Attack (Key Features)

• Sudden, spontaneous, intense anxiety lasting ~15–30 minutes

• *suicide risk

• Includes ≥4 symptoms:

  • Palpitations

  • SOB / feeling of suffocation

  • Chest pain

  • Dizziness

  • Nausea/abdominal distress

  • Sweating, tremors

  • Paresthesia, chills, or hot flashes

Agoraphobia

• Commonly r/t panic disorder

• Fear of being in places where escape may be difficult

• Involves staying in / near their home, possibly becoming homebound

Primary Gain

• Relief of anxiety by avoiding trigger
  → Example: staying home prevents panic

Secondary Gain

• External benefits as a result of the behavior
  → Example: increased attention from others, others assume responsibilities

tx

• CBT

• deep breathing and relaxation

• medications (benzodiazepines, SSRI antidepressants, tricyclic antidepressants, and antihypertensives such as clonidine (Catapres) and propranolol (Inderal))

panic disorder & nursing process

ASSESSMENT

• History: recurrent panic attacks; often misinterpreted as MI (“going crazy/dying”); no trigger

• Appearance/Behavior: may appear normal or anxious; ↑ speech, restlessness, automatisms (tapping, pacing)

• Mood/Affect: anxious, fearful, depressed; depersonalization/derealization

• Thoughts: disorganized during attack; fear of death/loss of control; possible suicidal ideation ⚠

• Cognition: confusion/disorientation during attack → resolves after

• Judgment/Insight: impaired during attack; insight develops with education

• Self-concept: self-blame, low self-esteem

• Roles/Relationships: avoidance → social/occupational impairment (agoraphobia)

• Physiological: poor sleep, appetite changes

NURSING DIAGNOSES (COMMON)

• Anxiety

• Risk for injury (priority)

• Ineffective coping

• Powerlessness

• Situational low self-esteem

• Disturbed sleep pattern

• Ineffective role performance

OUTCOMES (GOALS)

• Remains safe/injury-free

• Verbalizes feelings

• Demonstrates coping skills + anxiety control

• Verbalizes sense of control

• Improved sleep & nutrition

INTERVENTIONS (PRIORITY = DURING PANIC)

• Stay with client; maintain calm presence

• Provide safe, low-stimulation environment

• Use short, simple, reassuring communication

• Focus on deep breathing/grounding

• After attack:

  • Teach relaxation techniques

  • Use cognitive restructuring

  • Identify/reduce stressors & triggers

  • Provide client/family education

EVALUATION

• ↓ frequency/intensity of panic attacks

• Uses coping strategies appropriately

• Adheres to medications

• Reports improved quality of life

phobias

DEFINITION

• Intense, irrational, persistent fear of object/situation

• Out of proportion to actual danger

• Causes distress + impaired functioning

• Client may recognize fear is irrational but feels powerless

KEY FEATURES

• Anticipatory anxiety (fear just thinking about exposure)

• Avoidance behavior → restricts life (does NOT relieve anxiety long-term)

• Diagnosis only if significant impairment (not just mild fear)

CATEGORIES

1. Agoraphobia → fear of places where escape is difficult (home-bound)

2. Specific Phobia → fear of a specific object / situation

3. Social Anxiety Disorder (Social Phobia)

   • Fear of embarrassment/judgment

   • Low self-esteem

   • Examples: public speaking, eating, using public restroom

PATHOPHYSIOLOGY / BEHAVIOR

• Avoidance reinforces fear (negative reinforcement cycle)

TREATMENT

• Behavioral therapy = FIRST-LINE

  • Relaxation training

  • positive reframing and assertiveness training

  • Systematic / serial desensitization (gradual exposure to ↓ anxiety)

  • Flooding (rapid, intense exposure to the trigger in a safe environment→ ⚠ high anxiety for client, but aims to eliminate the phobia in 1-2 sessions)

Medications: SSRIs, anxiolytics

types of meds for anxiety disorders

Benzodiazepines

• lams and pams, for anxiety disorders & panic

Nonbenzos

• Buspirone / Buspar (can still drive the BUS)

• for anxiety & phobias

SSRI antidepressants

• Fluoxetine (Prozac)

• Sertraline (Zoloft)

• Paxil

tricyclic antidepressants

• Tofranil

alpha-adrenergic agonists

• propanolol (Inderal)

beta blocker

• Clonidine (Catapres)

obsessive-compulsive disorder (OCD)

• Involves recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses. The client knows they’re unreasonable but feels powerless to stop.

• Compulsions = ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety

  • self-soothing behaviors (trichotillomania- hair pulling; dermatillomania- skin picking; onychophagia- nail biting)

  • reward-seeking behaviors (hoarding, kleptomania, pyromania, or oniomania- buying excessively)

  • body dysmorphic disorder (BDD)- “the reason for my problems is bc of the way I look”

  • Body identity integrity disorder (BIID)- people who feel “overcomplete,” or alienated from a part of their body and desire amputation. This condition is also known as amputee identity disorder and apotemnophilia or “amputation love.” They may intentionally damage the body part until they medically need an amputation

• Checking rituals (repeatedly making sure the door is locked or the coffee pot is turned off)

• Counting rituals (each step taken, ceiling tiles, concrete blocks, desks in a classroom)

• Washing and scrubbing until the skin is raw

• Praying or chanting

• Touching, rubbing, or tapping (feeling the texture of each material in a clothing store; touching people, doors, walls, or oneself)

• Ordering (arranging and rearranging furniture or items on a desk or shelf into perfect order; vacuuming the rug pile in one direction)

• Exhibiting rigid performance (getting dressed in an unvarying pattern)

• Having aggressive urges (for instance, to throw one’s child against a wall)

diagnosed only when these thoughts, images, and impulses consume the person or he or she is compelled to act out the behaviors to a point at which they interfere with personal, social, and occupational functions

Can start in early childhood; in females, more commonly begins in the 20s

• Periods of waxing and waning symptoms over lifetime

• hereditary aspect

tx for OCD

Combination of medications and therapy

• exposure therapy

Medications:

• First line: SSRIs (fluvoxamine, sertraline- Zoloft)

• Second line: SNRI (venlafaxine- Effexor)

• Treatment-resistant OCD: second-generation antipsychotics (risperidone, quetiapine- Seroquel, olanzapine- Zyprexa)

OCD assessment & nursing process

TOOLS

• Yale-Brown Obsessive–Compulsive Scale (Y-BOCS)

HISTORY

• Seeks help when obsessions overwhelming or compulsions impair function

• Often long-standing (childhood onset)

• Mostly outpatient unless severe functional impairment

APPEARANCE & BEHAVIOR

• Tense, anxious, worried

• May appear “normal” overall

• Embarrassment discussing symptoms

• Severe cases → immobilized by anxiety/rituals

MOOD & AFFECT

• Persistent, overwhelming anxiety

• May appear sad/distressed

THOUGHT PROCESSES & CONTENT

• Obsessions = intrusive, unwanted, arise suddenly

• Attempts to suppress → increase intensity

• Client recognizes thoughts as irrational/unwanted

COGNITION

• Intact memory & intellect

• ↓ concentration when anxiety ↑

• No sensory impairment

Judgment

• client knows the obsessions are meaningless but feels powerless to stop

self-concept

• client feels they’re “going crazy” and feel powerless

possible nursing diagnoses for OCD

-Anxiety

•Ineffective coping

•Fatigue

•Situational low self-esteem

•Impaired skin integrity (if scrubbing or washing rituals)

Grounding & Coping with Dissociation

Nursing interventions for a client experiencing dissociation or flashbacks:

• Use grounding techniques → remind client they are present, safe, and an adult

• Approach calmly; call client by name; introduce self; reorient to time/place/situation (repeat as needed)

• Increase reality contact using 5 senses (“What do you see/hear/feel?”)

• Encourage movement (look around, stand, walk, focus on feet on floor)

• Do NOT grab or force touch; assess touch preference beforehand

• Help client identify emotions using a feelings log (rate 1–10)

• Identify triggers preceding episodes

• Teach coping strategies: deep breathing, relaxation, sensory focus, positive distractions (exercise, music, hobbies)

• Encourage keeping a personal coping list available

Goal: Increase emotional awareness, reduce dissociative symptoms, and improve self-regulation.

trauma and stressor-related assessments

Assessment

• It is generally not necessary or desirable for the client to detail specific events of the abuse or trauma. In-depth discussion of the actual abuse is usually undertaken during individual psychotherapy sessions.

General Appearance and Motor Behavior

• The client often appears hyperalert and reacts to even small environmental noises with a startle response. He or she may be uncomfortable if the nurse is too close physically. The client may appear anxious or agitated and may have difficulty sitting still, often needing to pace or move around the room. Sometimes the client may sit very still, seeming to curl up with arms around knees.

Mood and Affect

• A wide range of emotions is possible from passivity to anger. The client may look frightened or scared or agitated and hostile depending on his or her experience. When the client experiences a flashback, he or she appears terrified and may cry, scream, or attempt to hide or run away. When the client is dissociating, they may speak in a different tone of voice or appear numb with a vacant stare. The client may report intense rage or anger, or feeling dead inside and may be unable to identify any feelings or emotions.

Thought Process and Content

• Clients who have been abused or traumatized report reliving the trauma, often through nightmares or flashbacks. Intrusive, persistent thoughts about the trauma interfere with the client’s ability to think about other things or to focus on daily living. Some clients report hallucinations or buzzing voices in their heads. Self-destructive thoughts and impulses as well as intermittent suicidal ideation are also common. Some clients report fantasies in which they take revenge on their abusers.

Sensorium and Intellectual Processes

• The nurse usually finds that the client is oriented to reality except if the client is experiencing a flashback or dissociative episode. The nurse may also find that clients who have been abused or traumatized have memory gaps, which are periods for which they have no clear memories. Intrusive thoughts or ideas of self-harm often impair the client’s ability to concentrate or pay attention.

Judgment and Insight

• The client’s insight is often related to the duration of his or her problems with dissociation or PTSD. The client’s ability to make decisions or solve problems may be impaired.

Self-Concept

• The nurse is likely to find these clients have low self-esteem. They may believe they are bad people who somehow deserve or provoke the abuse. Many clients believe they are unworthy or damaged by their abusive experiences to the point that they will never be worthwhile or valued. Clients may believe they are going crazy and are out of control with no hope of regaining control.

Roles and Relationships

• Clients generally report a great deal of difficulty with all types of relationships. Problems with authority figures often lead to problems at work, such as being unable to take direction from another or have another person monitor performance. Close relationships are difficult or impossible because the client’s ability to trust others is severely compromised. Intrusive thoughts, flashbacks, or dissociative episodes may interfere with the client’s ability to socialize with family or friends, and the client’s avoidant behavior may keep him or her from participating in social or family events.

Physiologic Considerations

• Most clients report difficulty sleeping because of nightmares or anxiety over anticipating nightmares. Overeating or lack of appetite is also common. Frequently, these clients use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or memories.

flunitrazepam (Rohypnol)

date rape drug that perpetrators use to subdue victims

• used by violent offenders

Intergenerational Transmission Process

shows that patterns of violence are perpetuated from one generation to the next through role modeling and social learning

lack of protection for homosexual couples r/t IPV

homosexual victims may not be protected in the same way as heterosexuals bc of the state laws that exclude sodomy (anal intercourse) from counting bc it’s illegal.

cycle of violence or abuse

another reason often cited for why women have difficulty leaving abusive relationships.

1. violent episode- the initial episode of battering or violence

2. honeymoon period- a period of the abuser expressing regret, apologizing, and promising it will never happen again. He professes his love for his wife and may even engage in romantic behavior (e.g., buying gifts and flowers). The woman naturally wants to believe her husband and hopes the violence was an isolated incident.

3. tension-building phase - arguments, stony silence, or complaints from the husband. The tension ends in another violent episode after which the abuser once again feels regret and remorse and promises to change.

4. *This cycle continually repeats itself. Each time, the victim keeps hoping the violence will stop.

child abuse

the intentional injury of a child. It can include physical abuse or injuries, neglect or failure to prevent harm, failure to provide adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion, and overt torture or maiming.

• Physical abuse of children often results from unreasonably severe punishment such as hitting an infant for crying or soiling his or her diapers. Intentional, deliberate assaults on children include burning, biting, cutting, poking, twisting limbs, or scalding with hot water.

• The victim often has evidence of old injuries (e.g., scars, untreated fractures, or multiple bruises of various ages) that the history given by parents or caregivers does not explain adequately.

• Sexual abuse involves sexual acts performed by an adult on a child younger than 18 years (incest, rape, and sodomy performed directly by the person or with an object, oral–genital contact, and acts of molestation such as rubbing, fondling, or exposing the adult’s genitals). *A second type of sexual abuse involves exploitation, such as making, promoting, or selling pornography involving minors, and coercion of minors to participate in obscene acts.

• Neglect is malicious or ignorant withholding of physical, emotional, or educational necessities for the child’s well-being. Most prevalent. Also includes refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the child’s safety; punitive, exploitive, or abusive emotional treatment; spousal abuse in the child’s presence; giving the child permission to be truant; or failing to enroll the child in school.

• Psychological abuse (emotional abuse) includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm; constant family discord characterized by fighting, yelling, and chaos; and emotional deprivation or withholding of affection, nurturing, and normal experiences that engender acceptance, love, security, and self-worth. Exposure to parental alcoholism, drug use, or prostitution—and the neglect that results—also falls within this category.

red flags of abused children

• Serious injuries such as fractures, burns, or lacerations with no reported history of trauma

• Delay in seeking treatment for a significant injury

• Child or parent giving a history inconsistent with severity of injury, such as a baby with contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened when the infant rolled off the sofa

• Inconsistencies or changes in the child’s history during the evaluation by either the child or the adult

• Unusual injuries for the child’s age and level of development, such as a fractured femur in a 2-month-old or a dislocated shoulder in a 2-year-old

• High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina

• Evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that parent/caregiver cannot explain adequately

Often, these children talk or behave in ways that indicate more advanced knowledge of sexual issues than would be expected for their ages. At other times, they are frightened and anxious and may either cling to an adult or reject adult attention entirely. The key is to recognize when the child’s behavior is outside what is normally expected for his or her age and developmental stage. Seemingly unexplained behavior, from refusal to eat to aggressive behavior with peers, may indicate abuse.

nurses are MANDATORY reporters - even if we’re not 100% sure

catharsis

the process of releasing, and thereby providing relief from, strong or repressed emotions.

• AKA “purging” from an emotion like ANGER

Cultural considerations: Hwa-Byung, Bouffée délirante, Amok

Hwa-Byung

• Korean “fire illness”- Somatic complaints (chest pressure, heat sensation); Emotional outbursts after prolonged repression

Bouffée délirante

• French “sudden psychotic outburst”- delusions, hallucinations; Agitation or aggressive behavior. Usually short duration with full recovery. May resemble schizophrenia or brief psychotic disorder

Amok

• Sudden violent outburst (“running amok”)- Sudden, unprovoked violent behavior. Dissociative state, Followed by exhaustion or amnesia. Historically linked to shame or perceived insult. Assess for trauma

Treatment of Aggression

Treat the Underlying Disorder First!

• Aggression is often secondary to: Schizophrenia, Bipolar disorder, Dementia, Personality disorders, Brain injury, Intellectual disability

Medication Management:

Mood Stabilizers

• Lithium → Effective for: Bipolar disorder, Conduct disorder (children), Intellectual disability

• Carbamazepine (Tegretol) or Valproate (Depakote) → Used for aggression with: Dementia, Psychosis, Personality disorders

Typical Antipsychotics

• Haloperidol (Haldol)

• Thorazine

Atypical Antipsychotics (Preferred for psychotic aggression)

• Clozapine (Clozaril) → risk for agranulocytosis

• Risperidone (Risperdal) → increases prolactin (risk for gynecomastia & galactorrhea)

• Olanzapine (Zyprexa)

Effective in: Dementia, Brain injury, Intellectual disability, Personality disorders

**antipsychotics have crazy s/e: monitor for EPS!!!! → tx with Cogentin (benztropine)

Benzodiazepines

• Lorazepam (Ativan) → Best for non-psychotic agitation

Seclusion & Restraint

• Used short-term during crisis phase only

• For protection of client and others

• Strict legal and ethical guidelines apply

• Not a treatment — a safety intervention

phases of aggression

1. Triggering Phase- Event or stressor activates anger.

Signs/Symptoms

• Anxiety, Irritability, Pacing, Muscle tension, Rapid breathing, Argumentative behavior

Nursing Focus

• Use de-escalation techniques

• Encourage verbal expression of feelings

• Reduce environmental stimuli

• offer PRN meds or physical activity like walking

2. Escalation Phase- Client loses ability to problem-solve; anger intensifies.

Signs/Symptoms

• Increased motor activity, Loud voice, Threatening gestures, Hostility, Clenched fists, Poor impulse control

Nursing Focus

• Take control. Set clear, firm limits, direct to safe & private area.

• Maintain calm tone

• Offer PRN medication if refused earlier

• Prepare for possible safety interventions- “show of force” - bring 4-6 staff members into the room

3. Crisis Phase- Loss of emotional and physical control.

Signs/Symptoms

• Physical aggression

• Destruction of property

• Shouting/screaming

• Potential harm to self/others

Nursing Focus (Priority = SAFETY)

• Call for assistance

• Use least restrictive intervention first

• May require medication, seclusion, or restraint

• If restraints are used, get a physician’s order ASAP after. if meds were refused earlier, IM injection may be forced after receiving an order

4. Recovery Phase- Client regains control.

Signs/Symptoms

• Decreased muscle tension

• Slower breathing

• Regains ability to follow directions

• May appear confused or tired

Nursing Focus

• Maintain supportive presence

• Continue observation, offer sleep, relaxation

• document / assess injuries

• debrief w staff

5. Post-Crisis Phase- Client returns to baseline.

Signs/Symptoms

• Calm behavior, Rational conversation possible. Possible remorse, guilt, or denial

Nursing Focus

• remove restraints when recovered

• Identify triggers, Teach coping strategies, Modify care plan

• reintegrated into the milieu

rape / sexual assault

Assessment

To preserve possible evidence, the physical examination should occur before the victim has showered, brushed teeth, douched, changed clothes, or had anything to drink in order to complete a rape kit & collect evidence. (may not be possible if they did these otw to the clinic / hospital). If there is no report of oral sex, then rinsing the mouth or drinking fluids can be permitted immediately.

To assess the patient’s physical status, the nurse asks the victim to describe what happened. Rape kit is done gently. The physician or a specially trained sexual assault nurse examiner is primarily responsible for this step of the examination.

Treatment and Intervention

Victims of rape fare best when they receive immediate support and can express fear and rage to family members, nurses, physicians, and law enforcement officials who believe them.

Warning signs of relationship violence

expressing negativity about women, acting tough, engaging in heavy drinking, exhibiting jealousy, making belittling comments, expressing anger, and using intimidation.

elder abuse

Warnings of financial exploitation or abuse- numerous unpaid bills (when the client has enough money to pay them), unusual activity in bank accounts, checks signed by someone other than the elder, or recent changes in a will or power of attorney when the elder cannot make such decisions. The elder may lack amenities that he or she can afford, such as clothing, personal products, or a television.

The nurse may also detect possible indicators of abuse from the caregiver. The caregiver may complain about how difficult caring for the elder is, incontinence, difficulties in feeding, or excessive costs of medication. He or she may display anger or indifference toward the elder and try to keep the nurse from talking with the elder alone. Elder abuse is more likely when the caregiver has a history of family violence or alcohol or drug problems.

assessing IPV victims

Because most abused women do not seek direct help for the problem, nurses must help identify abused women in various settings. Nurses may encounter abused women in emergency departments, clinics, or pediatricians’ offices. Some victims may be seeking treatment for other medical conditions not directly related to the abuse or for pregnancy. The generalist nurse is not expected to deal with this complicated problem alone. He or she can, however, make referrals and contact appropriate health care professionals experienced in working with abused women.

post-traumatic stress disorder (PTSD)

a maladaptive stress response that occurs after a person has experienced, witnessed, or been confronted with a traumatic event involving actual or threatened death or serious injury.

• May feel intense fear or terror; Helplessness at time of trauma

Core Symptom Clusters (4 Categories)

1. Reexperiencing

   • Intrusive, recurrent thoughts, Flashbacks, Distressing dreams

   • Psychological/physical reactions to reminders

2. Avoidance

   • Avoids thoughts, feelings, conversations

   • Avoids people, places, or situations linked to trauma

3. Negative Cognition/Mood

   • Persistent negative beliefs

   • Emotional numbing

   • Loss of interest

4. Hyperarousal (Being “on guard”)

   • Hypervigilance

   • Exaggerated startle response

   • Irritability

   • Sleep disturbance

Screening Tools

• Life Events Checklist (LEC) → Screens for trauma exposure.

• PTSD Checklist (PCL) → Assesses symptom severity.

lack of social support, peri-trauma dissociation, and previous psychiatric history or personality factors can further increase the risk of PTSD when they are present pretrauma

Considerations for adolescents-

• more likely to develop PTSD than children or adults

• They are at increased risk for suicide, substance abuse, poor social support, academic problems, and poor physical health.

• less likely to get PTSD if they have a strong cultural connection & support

• Trauma-focused CBT can be delivered in school or community-based settings

tx

• Combination of psychotherapy + medication is most effective.

• Inpatient care is NOT routine, only for:

  • Suicidal risk / Severe flashbacks or crisis requiring stabilization

Psychotherapy (First-Line)

1. Cognitive Behavioral Therapy (CBT) – Most Effective. Addresses distorted thoughts, avoidance, and maladaptive beliefs

2. Exposure Therapy- Reduces avoidance behaviors. Client confronts trauma-related thoughts, emotions, or situations. Uses relaxation techniques to manage anxiety. Especially effective in military populations

3. Adaptive Disclosure- Short-term (6 sessions), military-developed CBT approach. Includes exposure + “empty chair” technique. Helps process unresolved emotions

4. Cognitive Processing Therapy (CPT)- Focuses on: Guilt, Self-blame, Faulty beliefs (“It was my fault”), Encourages realistic, balanced thinking. Effective in rape survivors & combat veterans

5. Group Therapy / Self-Help Groups- Provide support and shared processing. Promote normalization and connection

Medications (Symptom-Targeted)

Most Effective: SSRIs 7 SNRIs

• Second-generation antipsychotics (e.g., risperidone) may be used

Not strongly supported:

• Benzodiazepines (commonly used but limited evidence)

Used to treat: Insomnia, Anxiety, Hyperarousal

Rule out: Grief reactions, Autism spectrum disorder, Other mental health conditions

adjustment disorder

Maladaptive reaction to an identifiable stressor (financial, relationship, work).

Key Features:

• More distress than expected

• Impaired functioning

• Symptoms develop within 1 month

• Duration ≤ 6 months (if sx last longer than 6 months → reassess for another dx)

Treatment:

• Outpatient counseling/therapy (most effective)

Acute Stress Disorder (ASD)

Occurs 3 days to 4 weeks after trauma

Sx:

• Reexperiencing

• Avoidance

• Hyperarousal

⚠ Can progress to PTSD if unresolved.

Prevention of PTSD:

• Early CBT, Exposure therapy, Anxiety management techniques

Reactive Attachment Disorder (RAD) vs Disinhibited Social Engagement Disorder (DSED)

Onset: Before age 5
Cause: Severe neglect or abuse, institutionalization, “grossly pathogenic care”, severely deficient parenting

RAD

• Minimal emotional response

• Does not seek comfort from caregivers

• Limited positive affect

• May appear sad, irritable, fearful

DSED

• Overly familiar with strangers

• No hesitation approaching unfamiliar adults

• Unselective attachment behaviors

DISSOCIATIVE DISORDERS

Dissociation = subconscious defense mechanism that protects the person from overwhelming trauma.

• Allows the mind to detach from painful memories or events.

• Can occur during or after trauma.

• Becomes easier with repeated use.

Dissociation interferes with:

• Relationships

• ADLs

• Ability to cope with trauma

• Reality integration (though not psychosis in most cases)

Common in:

• Clients with PTSD

• Individuals with childhood physical/sexual abuse history

Three Main Types

1. Dissociative Amnesia

• Inability to recall important personal/traumatic information.

• May include fugue state:

  • Sudden travel

  • New identity

  • No memory of past

2. Dissociative Identity Disorder (DID)

• Two or more distinct personality states.

• Gaps in memory for important personal information.

• Formerly called multiple personality disorder.

• Diagnosis remains controversial.

3. Depersonalization/Derealization Disorder

• Depersonalization: Feeling detached from self/body.

• Derealization: Environment feels unreal or dreamlike.

• Client is not psychotic and remains reality-based.

Psychotherapy

• individual or group therapy

• focus on reassociation (integrating fragmented consciousness)

Medications

• Used symptomatically for Anxiety & Depression